tci ED Coding & Reimbursement Alert - 2016 Issue 3

You Be the Coder: Look for Documentation of Catheter Use Before Coding Thoracentesis

Question: A patient with shortness of breath reports to the ED. The physician documents the pertinent historical information and performs an exam including auscultation of the lungs, which sound muffled.  Percussing the patient’s chest produces a dull “thud.” A chest X-ray interpreted by the emergency physician confirms the presence of a large pleural effusion. Based on the evaluation, the physician decides to perform thoracentesis. After the patient is prepped, pleural fluid is withdrawn through a needle into a syringe and sent to the laboratory for analysis. The results indicate the presence of an exudative pleural...

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